Download FROM HYSTERICAL PSYCHOSIS TO REACTIVE DISSOCIATIVE

Onno van der Hart, Eliezer Witztum, Barbara Friedman
FROM HYSTERICAL PSYCHOSIS TO REACTIVE
DISSOCIATIVE PSYCHOSIS
Onno van der Hart
Eliezer Witztum
Barbara Friedman
This article was accepted for publication under the Editorship of Charles R. Figley.
Regional Institute for Ambulatory Mental Health Care, Amsterdam South/New West, Amsterdam, The Netherlands. To
whom reprint request should be addressed at Riagg Z/!N W, P.O. Box 71505, 1008 DA Amsterdam, Netherlands.
3
Jerusalem Mental Health Center-Ezrath Nashim, Jerusalem, Israel. 4Dissociative Disorders Institute, Los Angeles, California
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Abstract: In this paper Reactive Dissociative Psychosis (RDP) is seen as a post-traumatic stress response. and as
a subcategory of Brief Reactive Psychosis (BRP). A review of the literature and the evolution of RDP from
Hysteria and Hysterical Psychosis are given. Issue is taken with defining the duration of BRP as “Brief_ “ The
authors argue that long-standing psychotic symptoms may be traumatically-induced. The dissociative aspects of
RDP as its key feature and the concomitant implications for accurate diagnosis are proposed. The usefulness of
applying hypnosis in RDP treatment is summarized in a case study from Janet and detailed in a case from the
authors’ practice.
KEY WORDS: hysterical psychosis; reactive dissociative psychosis; brief reactive psychosis: posttraumatic
stress; dissociation; traumatic grief; hypnotherapy.
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Journal of Traumatic Stress, Vol. 6, No. 1, 1993
Onno van der Hart, Eliezer Witztum, Barbara Friedman
symptomatology and treatment rather than including the
etiological factors in HP. Ignoring this essential aspect
detracted from the importance of trauma in the onset of
certain disorders.
The role of trauma in the genesis of
psychopathology is being reexamined in the light of
new information emerging in the fields of trauma and
posttraumatic psychopathology. This information
requires assimilation with the historical thinking that
precedes. In the case of reactive psychosis, we use the
traditional nomenclature of HP in reviewing the
literature and propose a new category of
psychopathology-Reactive
Dissociative
Psychosis
(RDP). RDP integrates the classical features of HP with
the most -event thinking on trauma-induced psychosis.
In this paper we refer to the literature and summarized
cases with the term HP, then designate our case and
discussion as RDP, a term we find relevant and useful
in today’s clinical experience.
INTRODUCTION
Historically, Hysterical Psychosis was a rubric used to
designate
a
vast amount
of posttraumatic
psychopathology. Recent advances in the field of
traumatic stress now provide the means to differentiate
categories of traumatic stress responses. A notable
factor in this process was discovering the role of
dissociation as a primary defense in overwhelming life
events. Acknowledgment of dissociation in trauma will
be established in the DSM-IV, which will contain a
diagnostic category for acute stress reactions probably
called Brief Reactive Dissociative Disorder. It is useful
to trace the evolution of dissociation in psychology
through the history of hysteria, specifically, hysterical
psychosis.
The concept of hysterical psychosis (HP) suffered a
curious fate in the history of psychiatry. During the
second half of the 19th century this disorder was wellknown and thoroughly studied, particularly in French
psychiatry. In the early 20th century the diagnosis of
hysteria, and of HP, fell into disuse. Patients formerly
considered to suffer from HP were diagnosed
schizophrenics or malingerers. A few clinicians have
attempted to reintroduce this diagnostic category, but it
has not regained official recognition. One reason may
be that for many other clinicians the term “hysterical”
has pejorative connotations. The Index of the DSM-IIIR (APA, 1987) contains HP, then refers readers to
either Brief Reactive Psychosis or to Factitious Disorder
with psychological symptoms. Brief Reactive
Psychosis, first included in the DSM-II (APA, 1968),
was considered a response to major stress, such as the
loss of a loved one or the psychological trauma of
combat. Since evidence exists that a Reactive Psychosis
is not always brief (Breuer, 1895; Janet, 1984/5; Van
der Hart and Van der Velden, 1987), we report a recent
case study collaborating this position. In reviewing
early and recent literature on this posttraumatic stress
syndrome, we will emphasize the essential role of
traumatically-induced dissociation in the genesis of
reactive psychosis. The description and discussion of
our case example demonstrate the usefulness of this
dissociative component in forming both a diagnostic
impression and treatment approach, especially in
conjunction with hypnotherapy.
One of the first historical reports of HP in which
traumatic origins were clearly described and made the
focus of treatment was published in 1868 (Hoek, 1868;
cf. Van der Hart and Van der Velden, 1987). It concerned Rika van B., a young woman treated by the
Dutch physician Andries Hoek in 1851/2. Her traumata
included repeated abuse, rape, the drowning )f a
servant, and finally her fiancé’s suicide by drowning
when she broke her engagement. Rika decompensated
in response to his suicide. Her symptoms included
periods of continuous talking and raving; the
dissociative symptoms of amnesia, hallucinations and
pseudo-epileptic seizures; depression; and suicidal
urges. She experienced intense re-enactments of he
traumatic events, for which she was amnestic
afterwards. In the hypnotic state, however, she was very
lucid; she could explain what was the matter with her
and give directions to her physician regarding the
course of treatment Thus, it was of utmost important in
her cure that in the hypnotic state she had the ability to
narrate her traumas calmly.
Unfortunately, Hoek’s important case stood alone. It
is true that his French contemporaries, notably Moreau
de Tours (1845, 1855, 1865, 1869), were also studying
HP, but they were more preoccupied with describing its
resenting characteristics than with its traumatic origins
and its treatment in conjunction with this etiology. They
found the following four basic features of HP: (1) its
similarity to dreams, (2) its curability (using
psychotherapy), (3) its plasticity or polymorphism, and
(4) its analogy with chemically-induced (e.g., hashish)
“artificial delirium.” It was only through the works of
Janet, Breuer and Freud that a more complete
understanding of trauma-induced HP was possible.
REVIEW OF THE LITERATURE
During the past century and a half, many
publications on Hysterical Psychosis (HP) referred to its
traumatic origins. Important observations were also
made about the phenomenology of HP and its curability
through psychotherapy, particularly with the use of
hypnosis. Unfortunately, many of the authors
documenting
their
cases
concentrated
on
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Journal of Traumatic Stress, Vol. 6, No. 1, 1993
Onno van der Hart, Eliezer Witztum, Barbara Friedman
and (5) altered states of consciousness occur. As we
understand Janet, the subject experiences HP as a
waking dream based on a traumatic experience (Janet,
1894, 1898b). The subject presents in a delusional state
which has no apparent connection to his or her current
reality. However, the therapist may discover that it has
direct connection to a past reality.
Janet believed that HP can develop progressively.
Initially, a certain sequence of images (e.g., the
reenactment of a traumatic event) dominates the mind
during an hysterical attack. This traumatic content may
also occur during intervals between the attacks, finally
manifesting as a chronic psychosis. Janet speculated
that the latter represented the transformation from HP
into another form of mental illness.
Janet concurred with the observation of old masters
that HP was curable by means of psychotherapy. He
attributed this to the fact that the dissociative nature of
hysteria implies a high hypnotizability. Hypnotherapy
was thus the treatment of choice in these cases (cf. Van
der Hart et al., 1989). One of Janet’s examples
illustrating this principle concerned the case of Achille,
38, a business man with no prior history of pathology,
presenting with unintelligible speech and actions (Janet,
1894/5; cf. Nemiah, 1974; Witztum and Van der Hart,
1992). Achille saw and heard demons, felt possessed by
them, and behaved bizarrely. Viewing this state as
symptomatic, Janet believed there was another state,
dissociated from this one, in which Achille could
explain his illness (as with the case of Hoek’s
patient Rika van B.).. Evoking this dissociated state
through hypnosis, Janet elicited a lucid account of the
events that determined the content of Achille’s
delusional ideation. Rather than being proof of a
psychotic disorder, the delusional phenomena and state
proved to be symbolic references to a traumatic event so
overwhelming that it was dissociated, the traumatic
event was inarticulable and produced what appeared as
a psychotic state. Treatment consisted of neutralizing
the emotionally overwhelming event by working
through memories of the material using a variety of
hypnotic and psychotherapeutic techniques. After 1
month, the “demons” were vanquished and disappeared.
Achille no longer went into deep hypnotic states, and
pathological ideation ceased, indicating resolution of
the traumatically induced dissociation. The HP
produced by the dissociated trauma remitted
completely, unity of mind was reestablished, 3- and 7year follow-ups indicated Achille was doing well in all
respects.
HYSTERICAL PSYCHOSIS IN PIERRE JANET’S
DISSOCIATION THEORY
Following Moreau de Tours and others, Pierre Janet,
the most imortant French authority on hysteria and HP,
emphasized that HP constitutes a kind of waking dream
in which the subject eventually cannot differentiate
between the dream elements and normal perceptions
Janet, 394/5, 1901). “Hystericals dream very much
during the night and even during the day. (...) These
dreams have usually two characteristics: (1) They take
place in abnormal states or subconsciously. They
disturb the normal thought by diminishing the
disposable force of attention, but they do not mingle
with it. (2) They run generally on a small number of
subjects, and these subjects are always the same. The
dream may increase under various circumstances,
become complicated in all its smallest incidents, and
mingle with the normal perception” (Janet, 1901, p.
460).
Through clinical observation of numerous hysterical
patients, Janet established that these so-called dreams
were related to traumatic experiences (Janet, 1889,
1898a, 1911; cf. Van der Kolk et al., 1989). Some of
them were traumatic memories, i.e., reexperiences of a
trauma. Janet labeled these primary idées fixes or
primary emotional states (Janet, 1894, 1898b). Others
were “dreams” and fantasies based upon these traumatic
memories, and were called secondary idées fixes or
secondary emotional states (cf. Van der Hart and
Friedman, 1989). Janet considered traumatic memories
and related secondary idles fixes as dissociative
phenomena. He defined dissociation as the splitting off,
separation and isolation of certain parts (“systems of
ideas and functions”) of the personality from the
conscious awareness and control of one’s habitual
personality. These parts of the personality often remain
unknown to waking consciousness and start to lead lives
of their own. They alternate with conscious awareness
in dominating the patient’s behavior, or interfere with
conscious awareness (cf. Van der Hart and Horst,
1989). The simplest dissociative phenomena are the
primary and secondary idles fixes mentioned above.
The most complex are the alter-personalities of patients
suffering from multiple personality disorder (MPD),
which have their own identity and distinguish
themselves from the habitual personality.
According to Janet (1894/5), a psychosis could be
considered hysterical if its dissociative nature could be
established. The criteria for that are: (1) the psychosis is
embedded in dissociative phenomena, (2) the psychosis
itself should be a dissociated mental state, (3) a splitting
or doubling of the mind (dédoublement de la
personnalité) occurs, (4) subconscious phenomena exist,
The early views of Breuer and Freud (1893/5) on
hysteria and HP were strongly influenced by Janet, as
Breuer (1895) testified. They emphasized, among other
things, the traumatic origins of these disorders. Breuer
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Onno van der Hart, Eliezer Witztum, Barbara Friedman
hysterical characteristics who are exposed to traumatic
events. These events evoke and reactivate earlier painful
experiences and their associated affect such as
resentment and hate. Patients with HP exhibit a
lowering of consciousness, dreaming, fantasizing,
staring, inattentiveness and abulia. The disorder can be
complicated by other hysterical symptoms such as
abasia, astasia and aphonia. According to Hugenholz,
the duration of HP may vary from a couple of days to
several months. When the psychosis disappears, other
hysterical characteristics may continue to exist.
In France, Follin et al., (1961) returned to the old
literature of Charcot, Janet, and others, and the early
work of Freud and Breuer. They presented five cases of
psychotic and hysterical patients, concluding that the
unfortunate inability to distinguish between HP and
schizophrenia often lead to “the most serious
therapeutic errors.”
(1895) also pointed to the dream-like nature of HP and
to the often rapid alternation of such dreams with the
normal waking state. He believed that patients dreaming
these waking dreams were in a state of self-hypnosis
that the French termed “somnambulism.” Unlike Freud,
Breuer believed that such “psychotic states” could
persist for a long time, as exemplified by his famous
case of Anna O.
THE DECLINE OF HYSTERIA
At the beginning of the 20th century, interest M HP,
hysteria and hypnosis vanished. That psychological
trauma could be a major factor in the development of
these disorders was also forgotten. The few attempts to
establish the clinical validity of HP were not accepted
(cf. Regis, 1906; Mairet and Salager, 1911). Two
factors prompted this rejection: (1) The successful
campaign against hysteria as a respectable mental
disorder because it lacked an organic base
(Villechenoux, 1968; Maleval, 1981). Babinski (1901,
1909) strongly advocated this position. This success led
to regarding patients suffering from HP as malingerers
or as following suggestions. (2) Bleuler’s introduction
of the term “schizophrenia” (Bleuler, 1911/50) as a
diagnostic entity encompassing widely divergent mental
disorders, and the broad acceptance it gained
(Rosenbaum, 1980; Maleval, 1981). Bleuler’s influence
was so great, that after 1911 the majority of
psychiatrists, including Freud, no longer used the
diagnosis of HP (Maleval, 1981).
Only very few authors continued to stress the
importance of distinguishing between HP and other
psychoses. The German psychiatrist Raecke (1915)
emphasized the influence of extreme situational stress
in the development of HP. The Dutch psychiatrist
Breukink (1923) harked back to the work of Janet, other
French masters, Breuer and Freud. According to
Breukink, HP was characterized by the patient’s high
hypnotizability. Therefore it was readily accessible and
treatable by hypnosis. However, the all-encompassing
label of “schizophrenia” prevailed, and many authors
struggle with the clinical problem of hysteria and of
diagnosing psychoses which did not completely fit the
diagnostic criteria of schizophrenia (e.g., Carrot et al.,
1945; Claude, 1937; Courbon, 1937; Mallett and Gold,
1964).
In America, the influential work of Hollender and
Hirsch (1964) described two dominant characteristics of
HP: (1) a sudden and dramatic onset temporarily related
to a profoundly upsetting event or circumstance, and (2)
a short duration of less than three weeks. Its
manifestations include hallucinations, delusions,
depersonalization and grossly unusual behavior. They
believed that HP most commonly occurs when persons
with hysterical personalities encounter trying life
situations. The adjective “hysterical” is used here as a
synonym of “histrionic,” which is not what the old
French masters such as Janet had in mind; for them, HP
was dissociative psychosis.
Hirsch and Hollender (1969) distinguished three
different modalities of HP: (1) as socioculturally
sanctioned behavior, i.e., behavior determined by the
prevailing belief system in a given culture; (2) as
simulation of psychotic behavior; and (3) as true
psychosis with disruption and breakdown of ego
boundaries. Langness (1976) criticized the first
modality by stating that HP is usually considered to be
abnormal, both by the members of the culture and by
the investigator. Hirsch and Hollender’s second
modality, simulation, seems to have influenced the
DSM-III and the DSMIII-R where Factitious Disorder
with psychological symptoms is regarded as one of the
categories to which the term HP refers. This unfortunate
position can be traced back to the turn of the century
and the view held by Babinski and others that many
hysterical patients were malingerers.
THE RETURN OF THE DIAGNOSIS OF
HYSTERICAL PSYCHOSIS.
After World War 11, several attempts were made to
revive the concept of HP. In line with Janet’s
dissociation model, the Dutch psychiatrist Hugenholz
(1946) stated that HP can develop in individuals with
Richman and White (1970) considered HP to be
associated with anxiety related to death, aggression and
actual object loss. In line with them, Martin (1971)
viewed HP as a response to disrupted object relations,
particularly in the case of disturbed marriages.
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Onno van der Hart, Eliezer Witztum, Barbara Friedman
The following case report details an apt illustration
of the basic features of Reactive Dissociative Psychosis.
It also illustrates the efficacy of psychotherapy using
hypnosis.
Siomopoulos (1971) described HP as a pattern of
regressive behavior related to childlike thought activity
and merging of fantasy and reality, thus joining the old
views of Moreau de Tours and other French masters.
Pankow (1973) emphasized the non-schizophrenic
nature of HP.
AVRAHAM, PERSUCUTED BY A ‘DEMON’
In the following case example, hypnotherapy was the
primary treatment modality, enabling the therapists to
enter and transform the patient’s dissociated
experiences. Like related cases (cf. Aikins, 1923; Janet,
1894/5; Spiegel and Fink, 1979), the “devil” or a
“demon” played an important role, and the patient’s
pathological imagery was transformed using hypnosis.
The changes occurring during hypnosis led to
behavioral changes which were then reinforced by
various traditional psychotherapeutic techniques. On
October 16, 1986, terrorists threw three hand grenades
into a crowd near the Western Wall in the Old City of
Jerusalem, killing one person and wounding 69. Two
months later, Avraham, 35, an ultra-orthodox Israeli
Jew was brought to a Mental Health Outpatient Clinic
by his wife. During the intake session, Avraham
frequently cried and moaned as if in physical pain. His
affect was depressed. He was oriented to place and
time, but not to current events. His cooperation with the
therapists was so poor that it was impossible to evaluate
accurately for a thought disorder. He denied any
suicidal tendencies. Based on the fact that the clinician
was unaware of the trauma history, a tentative diagnosis
of Major Depressive Episode was made, and
antidepressant medication (Imipramine, 150 mg.) was
initiated. As the trial with medication was unsuccessful
and the patient continue to deteriorate, Avraham was
referred to the authors EW and OvdH for treatment.
Avraham, accompanied by his wife, attended therapy
weekly. During the first 3 sessions, the following
background information was gathered from Avraham’s
wife, as the patient hardly spoke. Avraham’s past
medical history was unremarkable and he had no
previously defined psychiatric history. His father,
Avraham’s first Torah teacher, was in his time, a wellknown oriental orthodox rabbi in the Kabalist tradition.
He was killed in a car accident when Avraham was 8
years old. His mother never recovered from her grief
and was incapable of caring for Avraham and his 8
siblings. At the age of 12 he was placed in an
orphanage. He studied in a series of orthodox Yeshivas
(religious schools that emphasize Jewish studies to the
exclusion of secular subjects). At 20, he married and
had 5 children. As an observant Jew, Avraham
frequently went to the Western Wall, the last remains of
the Second Temple, the most sacred site in Judaism.
Praying there was a continuation of his father’s
religious habits. Avraham was thus engaged during the
DISSOCIATION REDISCOVERED
Janet’s dissociation model reappeared in the work of
Pringuet (1977) who underscored the dissociative
aspects of HP, including the splitting or doubling of the
personality, conversion symptoms so-called and suggestibility_ For Spiegel and Fink (1979), HP usually
involves brief and intense periods of psychotic
behavior, generally with graphic decompensation,
severe environmental stress and rapid recompensation
in individuals with other hysterical features. It remains
unclear whether histrionic or dissociative phenomena
comprise the “other hysterical features.” These authors
did not use the concept of dissociation, yet their view
that patients with HP are highly hypnotizable (while
patients who are schizophrenic and psychotic are not),
corresponds with Janet’s. Furthermore, they stated that
the former have a poor response to antipsychotic
medication, but will respond to individual and family
therapy. Follin et al.’s (1961) warning that the
confusion of both disorders may lead to “the most
serious therapeutic errors,” refers precisely to this point.
Spiegel and Fink regarded HP as a spontaneous,
undisciplined trance state, which they would most likely
consider a dissociative phenomenon now (cf. Spiegel,
Hunt and Dondershine, 1988).
Steingard and Frankel (1985) stated that dissociation
underlies the fact that certain highly hypnotizable
persons are prone to experience transient but severe
psychotic states while in spontaneously occurring trance
states. In harmony with the experiences of old masters
such as Hoek, Janet and Breukink, they believed
hypnotherapy to be the treatment of choice. In
conclusion: our review of old and more recent
publications which are positive with regard to the
diagnosis of HP seems to indicate that HP is a
traumatically induced dissociative psychosis, which is
manifested in spontaneously occurring trance states.
During these trance states either reenactments of
traumatic experiences or more symbolic experiences related to the trauma occur. Furthermore, these reports
agree on psychotherapy, in particular using hypnosis, as
the treatment of choice. As indicated, we believe that
the name Reactive Dissociative Psychosis (RDP) would
do more justice to this trauma-based disorder and
increase the likelihood of its recognition in
contemporary clinical practice.
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Onno van der Hart, Eliezer Witztum, Barbara Friedman
Whenever the traumatic event at the Western Wall
was mentioned in session, the therapists observed that
Avraham made agitated arm movements: First upward
and then back and forth horizontally. Following Janet,
they regarded these movements as expressions of
flashback phenomena-dissociative episodes during
which Avraham reexperienced the trauma. They
investigated the idea that these movements were iconic
representations of overwhelming experiences during the
attack-the explosions, people falling and running into
each other in panic. When they inquired about this, the
patient, who until then had barely spoken in sessions,
verified it and started haltingly to explain what had
happened. From then on, he could verbally
communicate with the therapists.
During following sessions Avraham and his wife
explained that his frequent prayers at the Western Wall
had a dual nature: The religious purpose and an attempt
to establish a rapport with his late father. The attack
shattered Avraham’s defenses against the unresolved
traumatic grief following his father’s untimely death.
His subsequent compulsive eating was his effort to fill
the deep emptiness he felt at the loss of his father. The
therapists made this unresolved grief the focus of
treatment. They asked Avraham to write a leave-taking
letter to his father in which he could tell him everything
he wanted and needed to tell him (cf. Van der Hart,
1983). Avraham’s wife assisted him in this task and the
letter he brought to the next session began with the
words, “Father, father, father, why did you leave me?
Why didn’t you come when I was married?” The
handwriting in the first sentence was appropriate for a
35-year old man, but it quickly degenerated into a
disorganized pattern, with large letters typical of the
handwriting of a young child, and by the end it had
become scribble. Avraham was asked to read the letter
aloud, and the same regression between episodes of
screaming and hitting himself vigorously on the chest,
and episodes of sinking into a state of masticatory
movements of sucking and rocking back and forth. The
traumatized child part of his personality reexperienced
the intense grief of the loss of his beloved and powerful
father. With deep emotion he’ expressed the feeling that
he would “forever be alone, that life would never be the
same, and that forever there would only be a cloud of
emptiness_” After this session, Avraham was very
upset. The frequency of his nocturnal persecutory
attacks increased and persisted into the day as well He
began to eat even more. The rapid weight gain caused
additional medical complications which often prevented
him from attending the scheduled therapeutic sessions.
The therapists realized their error in not exploring the
nature of these intrusive episodes and decided to do so
immediately.
The nocturnal persecutory attacks prompted by his
evening when the hand grenades were thrown. He was
not hit, but the force of the explosions threw him into
the air. As far as he remembered, he had not been
unconscious.
According to his wife, Avraham immediately
returned home. She noted a marked change from his
normal behavior over the next two weeks. He began
talking to himself in fragmentary sentences, speaking
constantly of bombs and people dying. He was easily
startled and distracted. He lost interest in his family. In
the third week, he began to consume huge quantities of
food, even compulsively taking food from his childrens’
plates. Over the next month, he gained more than 15kg,
developing peripheral edema and episodes of cellulitis
which required medical attention. During the fifth week
he withdrew further, had extensive crying spells and
was obviously depressed. He experienced severe sleep
disturbances, including insomnia and periods of
shouting _and crying during apparent sleep. He refused
to bathe, shave, or change his clothes, completely
neglecting personal hygiene and appearance. He was
dismissed from the Yeshiva, and the family lost its sole
source of income. Apart from his deranged behavior,
which led his wife to bring him to the Clinic, the
family’s deteriorating economic situation became a
stressful factor of increasing magnitude.
Despite the patient’s initial presentation as psychotic,
he was not responsive to Ridazine (600mg) which was
withdrawn along with Imipramine after one month.
Because the precipitating event was traumatic and
followed by rapid deterioration, Psychotic depression,
Brief Reactive Psychosis, and even Schizophreniform
Disorder were possible diagnoses. However, the patient
was not responsive to medication and his symptoms
persisted for several weeks. Physical and neurological
examination, including a CAT Scan, indicated no
pathology.
The therapists began considering another possibility.
They noticed severe regressive characteristics:
Avraham’s behavior resembled that of a frightened
child-his affect was terrified rather than detached or
remote. He showed no psychotic aggression. The
content of his “delusions” was polymorphic, bizarre and
colorful, but also ambiguous and vague. These features
led to the formulation of another clinical impression:
Avraham’s symptomatology was a posttraumatic stress
response with strong dissociative features. In the
terminology proposed in this paper, it was thought that
he suffered from a RDP. As more evidence emerged to
support this position, the therapists initiated a treatment
plan accordingly.
TREATMENT
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Journal of Traumatic Stress, Vol. 6, No. 1, 1993
Onno van der Hart, Eliezer Witztum, Barbara Friedman
“demon” again became frightened. “Black” now
enlisted two aides, and this demonic triad tried, almost
successfully, to drown Avraham when he was in the
Miqveh (ritual bath). In session, under hypnosis, Avraham saw both aides, one of whom was changed into
the form of a black dog. The therapists asked where
“Black” was. Avraham fearfully replied that it was
trying to sneak into the gutter over the room. The
therapists instructed him to demand that “Black” reveal
itself and state its name. With the therapists’ support,
Avraham complied. His insistence resulted in the
“demon” and its aides running away.
Therapy reached a stalemate, as Avraham could not
engage the demon. In the next session, Avraham was
asked to visualize the setting where he had last seen the
“demon” and its aides. “A desolate place in the desert,”
was his reply. The therapists interpreted this as a
metaphoric kernel statement (Fernandez, 1977),
expressing his problematic life situation. The “demon”
and its two aides were hidden behind nearby boulders.
The therapists urged Avraham to search for signs
indicating the direction he should take in order to find
protection. At first he saw nothing, then encouraged to
scan the horizon, he found a distant, small spot of green.
It was suggested that this might be an oasis where he
could find shelter, water, food and the company he was
looking for, the latter being an indirect suggestion for
symbolically meeting his father. When the therapists
suggested that Avraham walk in that direction, the
“demon” and its aides immediately appeared, trying to
distract him from going his own way. (This symbolized
the struggle of separating and becoming independent.)
He was asked to demand their names and to lure them
toward him, holding them captive until they gave their
names. The fact that they were still too afraid to approach him restored some self-confidence in the patient.
At the end of the session he was asked how old he felt.
“12,” he answered: Older than before.
Avraham continued his imagery process at home
with his wife’s assistance. During the next session he
was encouraged to persevere toward the “green,”
despite the obstacles and recurrent attacks of the
“Black” triad. Avraham and his wife reported that at
home the number of episodes involving the “demon”
was greatly reduced, and Avraham felt more confident
in his ability to control the “demon.” During one
therapy session the black dog suddenly appeared, and
Avraham repelled it by throwing an imaginary stone.
Afterwards he reported his age as 14.
During the next session Avraham reported having
found a new and powerful ally in his struggle with the
demons: The very famous Tsaddik (righteous man),
Rabbi Chaim Ben Attar (1696-1743). Avraham had
visited the grave of the Rabbi on the anniversary of his
death (Hillula) earlier that week. It is believed that such
unresolved mourning entailed terrifying experiences
which occurred during sleep, the transition state from
sleeping to waking, and finally, during the waking state
itself. In them Avraham was threatened by a figure
whom he initially described as “the Black.” Additional
information from himself and his wife, who kept a diary
on these attacks, revealed that this very ugly figure was
nonhuman, had red eyes and the legs and feet of a
chicken, the stereotypical description of a demon in
traditional Jewish folk religion. When this vision
occurred, Avraham would run around the room shouting
for help and hitting his head against the wall, trying
vainly to shake off the frightening images. During this
period he refused to leave the house and kept all
windows and curtains closed because he felt people
were trying to kill him.
To access and understand the whole picture, the
therapists decided to use hypnosis as a means of
entering and controlling these frightening dissociative
experiences. Hypnosis was very easily induced.
Avraham was directed to see the black figure who was
mocking and threatening him: “I killed your father and
now I will kill you like I killed your father.” Avraham
also reported seeing his father standing in the shadows
looking at him sadly. He cried to his father for help, but
the father could not help him. He tried to escape from
the black figure, but was unable to do so. He could
admit that the figure was a “demon,” a courageous
admission in light of the cultural taboo against naming
or discussing demons.
In the next sessions the therapists assisted Avraham
in gaining some control over this demon. Under
hypnosis he was given the traditional instructions for
exorcising a demon. Whenever he saw the black figure,
he was to incant loudly and clearly: “Go, go, go away,
because you do not belong to our world.” He used this
incantation in hypnosis during the session and saw the
“Black” running away. At home in the presence of his
wife it was effective, but when Avraham tried to utter it
alone it was not.
In order to promote Avraham’s independent coping
ability when alone with the demon, the therapists
instructed him to demand forcefully that the “demon”
give its name. This suggestion derived from traditional
beliefs that knowing and identifying a demon by name
is a prerequisite for overpowering it. Avraham
rehearsed this during the session, but the “demon”
refused to disclose its identity and ran away. To
generate a greater sense of self-control, the therapists
taught Avraham self-hypnotic relaxation techniques to
practice at home with his wife’s assistance. During the
next session, he reported some improvement using these
techniques. When he, in the company of his wife,
demanded that the “Black” reveal its name, the
7
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Journal of Traumatic Stress, Vol. 6, No. 1, 1993
Onno van der Hart, Eliezer Witztum, Barbara Friedman
embraced him also. Next he met his own Rabbi who
had died in a traffic accident when Avraham was 18. He
described these experiences with wonder, excitement
and joy, using Biblical verses to express his feelings. At
the end of the session, the therapists suggested that from
then on Avraham would have the power of Rabbi
Chaim Ben Attar with him, plus the additional
protective power of the Tsaddikim, his father,
grandfather and former Rabbi. Internalizing their
positive qualities would enable him to be a more
functional husband and father. Closing suggestions
were given for a comfortable, uninterrupted sleep.
a pilgrimage on the death anniversary is an effective
panacea (cf. Bilu and Abramovitch, 1985). A request
made on this day at the grave of a Tsaddik will be
granted. Avraham visited the grave on the Mount of
Olives with many others, but afterwards remained there
alone. He cried, asked for Help and prayed for many
hours. Finally he felt that his prayers were answered.
After that he felt supported by this Tsaddik and
experienced himself as more powerful. (This event
signified an important shift in the development of an
internal locus of control. Without direct suggestions
from the therapists, Avraham initiated action to solve
his problem. He began assuming responsibility for his
situation and enlisted the help of a wise and powerful
father figure which he internalized.) At home, he
worked with his wife to come closer to the green area,
determined to reach it during the next session.
FOLLOW-UP
In the next and final session Avraham’s wife
brought no notes from home. For the first time in 6
months, “There was nothing to report.” Avraham was
sleeping well at night, and apparently all hallucinations
and delusions had disappeared. Avraham felt very good,
albeit a bit weak. He had spent considerable time in
healthy interaction with his children. Both he and his
wife felt that his visit to the Lower Paradise had been
something of a mystic miracle, a great privilege which,
traditionally, is granted to only a few very righteous
men. Avraham did not want to undergo hypnosis again,
as the experience in the Lower Paradise felt completed.
During the preceding week, on the anniversary of his
father’s death, he had visited his father’s grave and
cried intensely. Afterwards, he felt greatly relieved.
(This completed the mourning seen as therapeutically
necessary to release the dissociated affect of the first
traumatizing event.) The couple thanked the therapists,
giving each of them a Book of Psalms as a gift.
Avraham said that he prayed daily for their well-being.
Soon afterwards the couple went on holidays, for the
first time in their lives. Then their debts increased, they
moved to a cheaper apartment, creditors hounded them,
and they verged on starvation. Under these pressures,
Avraham again experienced sleep disturbances.
However, he did not decompensate or experience
psychotic ideation. Three months after the final session
a social agency provided the family with financial
support and Avraham began a weight reduction
program. Avraham’s wife gave birth to another child 18
months later. At that time Avraham functioned
relatively well. He experienced mild sleep problems and
was a bit phobic of cars, but evidenced no psychotic or
paranoid ideation or signs of depression.
In this 18th session, Avraham described the green
area as a beautiful garden surrounded by a high wall. He
circled it and found a gate. Approaching it, he smelled
fragrant aromas from the garden. Suddenly, the “Black”
and its aides tried to grab him and throw him in a pit;
but with the power of the Tsaddik and the therapists’
encouragement, he showed that the balance of power
had definitely changed. He actually shouted to the
“demons:” “In the name of Rabbi Chaim Ben Attar, I
tell you, go away! I am not afraid of you. Go away. He
invoked verses from the Psalms: “He that dwells in the
secret place of the Most High shall abide under the
shadow of the Almighty...” (Psalms 91, 1). He stood in
the center of the therapy room, actually fighting with his
arms and legs, until at last he overcame the “demons”
and they withdrew, defeated. Next he approached the
guardian at the gate, explained that he had to enter the
garden, and asked permission to enter. (This reflected
both Avraham’s sense of entitlement and recognition of
boundaries: two new behaviors that resulted from
claiming his sense of power after conquering the
demons.) From outside, he saw many beneficent, whitebearded Tsaddikim. Suddenly he saw his father among
them, called to him and asked him to instruct the
guardian to let him in. Avraham’s affect changed
remarkably as he informed his wife and therapists that
he was entering the Lower Paradise, that the air smelled
like perfume, and that he saw two springs of water.
(Avraham’s experience of the Lower Paradise was
consistent with traditional descriptions of this wellknown place in Jewish mythology.) Encouraged to
drink and satisfy his thirst, he described the water as
sweet and fresh. He himself appeared completely
revitalized.
Then he saw his father again and ran to him,
embracing him and talking to him joyfully. He saw his
admired grandfather, for whom he was named and
8
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Journal of Traumatic Stress, Vol. 6, No. 1, 1993
Onno van der Hart, Eliezer Witztum, Barbara Friedman
DSM-III-R. Dissociating the experiencc from normal
consciousness is the primary defense against trauma
(Janet, 1889, 1894, 1911; Putnam, 1985, 1989; Spiegel,
1986, 1988). Dissociation leads to the formation of
mental systems outside the experiencing ego
(dédoublement de la personnalité), as Janet and his
contemporaries observed. In their simplest form these
systems consist of “traumatic memories.” These
traumatic memories can, however, become more
complex, establish a sense of self, and develop into the
alter-personalities
which
characterize
Multiple
Personality Disorder. In the case presented, the
traumatic memories were organized around a demonic
figure which provided the means for investigating the
dissociated experience. We propose that for a psychosis
to be RDP, its dissociative nature must be established.
According to Janet, this is apparent in the alteration
of different states of consciousness, the existence of
subconscious phenomena, and high hypnotizability.
This alteration of states of consciousness is referred to
in modern literature as the intrusion of traumatic
memories, flashbacks and nightmares. The rapid and
persistent intrusion of these traumatic phenomena into
normal daily life creates an alternative reality in which
the subjects experience themselves; at best the intrusion
is minimal, at worst, it alternates increasingly with
current reality until it dominates (Friedman, 1989). We
suggest that RDP occurs at the stage when a patient
experiences significantly diminished periods of
normalcy, and immersion in the traumatic phenomena
becomes pervasive. It is the subjective experience of
this dual reality that distinguishes the psychotic feature
of RDP.
While the disturbance resulting from posttraumatic
psychopathology may at some stage produce psychotic
features, psychotic behavior and ideation do not persist
once their traumatic origins in reality have been identified. In fact, it is this discovery of the correct reality
which seems to cause symptoms to subside. As our
example illustrates, even when the patient’s behavioral
responses do not seem appropriate to the present reality,
the patient can narrate the delusional content, comment
on it as an observer, recall and refer to it after
experiencing it. These are the functions most often
impaired in psychosis. To clinicians schooled in the
principles of traumatic flashbacks and reenactments,
the.. patients’ responses are, in fact, appropriate to their
subjective experiences at the time. Furthermore, when
their posttraumatic (RDP) episodes are resolved,
patients return to their former levels of functioning,
indicating that the nature and degree of organization in
thought processes was operational prior to the trauma.
Other authors emphasize high hypnotizability,
which they, too, consider to be dissociative in nature
(Breukink, 1923; Spiegel and Cardena, 1990; Spiegel
DISCUSSION
REACTIVE DISSOCIATIVE PSYCHOSIS
The immediate cause of RDP is usually a traumatic
or stressful life event. The DSM-111-R category for
Brief Reactive Psychosis indicates that BRP is a
posttraumatic stress response, as is PTSD. We believe
that in addition to environmental stressors, subjective
factors are sufficiently traumatizing to produce a
posttraumatic stress response. The terrorist attack in the
case of Avraham illustrates the objective nature of the
trauma. Avraham’s enduring belief that his father
abandoned him emphasized the subjective aspect. This
case illustrates Janet’s and Hugenholz’s observations
that in certain subjects a traumatic experience activates
previous traumatic memories, giving rise to the
phenomenon of double emotion (Janet, 1903, 1928).
Double emotion results from the observation that
traumatic memories can be triggered either by cognitive
associations or by “new” emotions (Janet, 1904). In
some cases, previous traumatic memories are activated,
giving rise to the phenomenon of double emotion,
relating to both past and present.
While it is recognized that PTSD may become
chronic, in Brief Reactive Psychosis a short duration is
regarded as a necessary condition. According to
Hollender and Hirsch (1964), HP lasts no longer than 3
weeks; the DSM-111-R allows for a duration of one
month for Brief Reactive Psychosis. Earlier references
refer to a short duration, but add the possibility of
frequent relapses.
Convincing arguments as to why this criterion is
essential have not been given, however (cf. Jauch and
Carpenter, 1988a&b). Breuer’s (1895) view that HP
could just as well develop into a more chronic condition
has never been refuted. Our case of Avraham and
Janet’s case of Achille, which we consider examples of
Reactive Dissociative Psychosis, and other cases (Hoek,
1868; cf. Van der Hart and Van der Velden, 1987;
Breukink, 1923; Hugenholz, 1946) support the notion of
a longer duration. It is possible that chronic RDP
becomes another kind of disorder, as Janet (1893/1901)
speculated, and this, too, requires further study.
We believe that the essential characteristic for
accurate diagnosis of RDP is not a short duration, but a
dissociative foundation. It could, therefore, also be
argued that RDP should be placed under the category of
the dissociative disorders, just like the Brief Reactive
Dissociative Disorder.
DISSOCIATION AS A RESPONSE TO TRAUMA
The dissociative foundation of RDP is a more
meaningful explanatory principle than an hysterical
or histrionic character as currently indicated in the
9
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Journal of Traumatic Stress, Vol. 6, No. 1, 1993
Onno van der Hart, Eliezer Witztum, Barbara Friedman
and Fink, 1979; Steingard and Frankel, 1985). Our
patient showed a great trance capacity, as did Janet’s,
although Achille was initially difficult to hypnotize.
CULTURAL ASPECTS
Avraham’s case aptly illustrates Langness’ (1976)
position against RDP as socioculturally sanctioned
behavior. His visual hallucinations fit Wing, Cooper
and Sartorius’ (1974) definition of a dissociative
hallucination. Although the demons and Tsaddikim in
Avraham’s dream were collective symbols in a
“particularized mythic world” (Dow, 1986), his
behavior was clearly seen as abnormal in his
community and even led to his dismissal from the
Yeshivah. For successful treatment, it was essential to
join and validate this “mythic world” as well as the
more general cultural background of the patient (cf. Bilu
et al., 1989). Using traditional counter demonic
measures such as incantations, the examination of the
real form of the “Black” and its aides, the demands that
it reveal its name and identity, and the therapists’
integration of the patient’s own language via reiterations, blessings, prayers and Biblical verses in their
communications accomplished this task.
HYPNOTHERAPY
It is known that patients with dissociative states,
acute and chronic alike, do not respond well to
medication. In their textbook Klein et al., (1980)
remark about dissociative reactions, that “these
reactions
are
essentially
refractory
to
psychopharmacological treatment” (pp. 560/1). With
regard to MPD, there is no evidence that medication of
any type has a direct therapeutic effect on the
dissociative process as manifested in this severe
dissociative disorder (Barkin et al., 1986). As for
RDP, there are case reports confirming and supporting
the clinical observation that these patients do not
respond well to psychopharmacology (Spiegel and Fink,
1979; Steingard and Frankel, 1985; Waldfogel and
Mueser, 1988). This is clearly an area which has been
insufficiently studied. Therefore, our conclusion must
be regarded as tentative, and further study is urgently
needed.
The fact that patients with RDP usually have a high
degree of hypnotizability suggests that psychotherapy,
particularly with the use of hypnosis, may be the
treatment of choice (cf. Breukink, 1923; Janet, 1898a;
Spiegel and Fink, 1979; Steingard and Frankel, 1985).
Hypnosis can be used to identify and influence the
traumatic experiences that produced the psychotic ideation. In Avraham’s case, hypnosis was used to learn the
nature of his subjective experience of the demon,
enabling the therapists to instruct the patient in
defending against it. The nonhypnotic treatment
technique of letter-writing intensified his demonic
hallucinations. To be effective for him, the patient
needed to formulate a defense system based on
traditional mystical sources that were part of his cultural
background. The therapists then used the hypnotic
technique of guided imagery to transform the patient’s
metaphoric kernel statement of desolation into a more
positive one (cf. Van der Hart, 1986; Witztum et al.,
1988). In imagery, the patient’s arduous journey from
the desert to the green spot ended in a joyful reunion
with his father in the Lower Paradise. This event in the
imagery domain coupled with the actual visit to his
father’s grave constituted the resolution of his chronic,
traumatic grief (cf. Van der Hart et al., 1990).
Our conclusion that psychotherapy using hypnosis
may be the treatment of choice for patients with RDP is,
in fact, based on a limited number of both contemporary
and historical case studies, not on systematic research.
This approach is in need of careful study under
prospective and rigorous experimental conditions.
CONCLUSION
Theoretical notions about the symbolic and
dissociative nature of trauma-induced Reactive
Dissociative Psychosis were conceptualized a century
ago as Hysterical Psychosis. HP reexamined through
knowledge of trauma in historical and current case
studies, suggests that this disorder can be diagnosed as a
form of posttraumatic stress disorder with dissociation
as its dominant feature. In the absence of response to
psychotropic medication, psychotherapy with hypnosis
could in some cases provide an effective treatment
approach. A recent traumatic event can trigger and
combine with past traumata in forming the
representational nature of the symptomatology.
Awareness that the content of traumata can appear in
symbolic form alerts the clinician to go beyond the
obvious conceptualization of psychosis and thoroughly
observe subjects’ thought processes and orientation to
reality over time. Hypnotic procedures may help
therapists enter the patient’s world, join and utilize the
patient’s idiosyncratic symbols and cultural symbology
to transform this inner world. We suggest that when a
psychotic presentation follows a traumatic event, this
approach to Reactive Dissociative Psychosis may in
certain cases provide effective treatment in the recovery
from posttraumatic stress. Certainly more, and more
systematic, studies are needed.
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Journal of Traumatic Stress, Vol. 6, No. 1, 1993
Onno van der Hart, Eliezer Witztum, Barbara Friedman
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Onno van der Hart, Eliezer Witztum, Barbara Friedman
Van der Hart, O., and Van der Velden, K. (1987). The hypnotherapy of Dr. Andries Hoek: Uncovering hypnotherapy
before Janet, Breuer, and Freud. Am. J. Clin. Hypn. 29: 264271.
TRAUMA-INDUCED PSYCHOSES
L’hypnose dans l’evaluation et le traitement de psychoses provoquées par traumatismes: la psychothérapie
pionnière de H. Breukink et vision plus moderne Onno van der Hart et David Spiegel
Résumé: Le rôle de I’hypnotisabilité dans le diagnostic différentiel de patients psychotiques est toujours
problématique. Darts cet article, les travaux pionniers du psychiatre hollandais H. Breukink (1860-1928), durant les
années 20, servent de base pour documenter l’utilité clinique de Yhypnose afin de différentier les patients
psychotiques fortement hypnotisables avec une symptômatologie dissociative, des patients schizophrènes. De plus, il
existe une longue tradition quant a l’utilisation de la capacité hypnotique dans le traitement des psychoses
dissociatives. La façon dont Breukink utilisait l’hypnose pour des fins de diagnostic, de pronostic et de traitement est
résumée et discutée a la lumière des conceptions anciennes et modernes. Breukink avançait l’idée que la psychose
hystérique était induite par traumatisme, certainement guérissable, et que la psychothérapie utilisant l’hypnose constituait un traitement de choix. L’hypnose était utilisée dans un cadre de thérapie orientée sur les symptômes, comme
un état mental confortable et sécurisant et aussi pour faire émerger les souvenirs traumatiques et les intégrar. Pour ce
dernier usage, Breukink recommande l’utilisation d’un état de calme mental, autant en hypnose qu’en état d’éveil, et
décourage l’expression emotive qu’il considère comme dangereuses chez les patients psychotiques. Dans la
discussion, une attention spéciale est accordée au rôle et dangers de l’expression des emotions reliées au
traumatisme.
Evaluacion y tratamiento hipnotico de psicosis traumaticas:
la psicoterapia primitiva de H. Breukink y una vision contemporanea Onno van der Hart y David Spiegel
Resumen: El rol de la evaluacion de la hipnotizabilidad en el diagnóstico diferencial de pacientes psic6ticos no ha
sido resuelto todavia. En este estudio, el trabajo pionero realizado durante los años 1920 por el psiquiatra holandés
H. Breukink (1860-1928) es utilizabo como una evidencia temprana de que la capacidad hipn6tica es clinicamente
útil para diferenciar pacientes psic6ticos con sintomatologia disociativa y altamente hipnotizables de los pacientes
esquizofrénicos. Además existe una larga tradición en el empleo de la capacidad hipn6tica en el tratamiento de éstas
psicosis disociativas. Las maneras en que Breukink utilizó la hipnosis para diagnóstico, pronóstico y tratamiento son
repertoriadas y discutidas a las luz de los puntos de vista contemporáneos y de la época. Breukink pensaba que la
psicosis histérica era inducida traurnáticamente, ciertamente curable y que la psicoterapia que utilizaba la hipnosis
era el tratamiento de elección. Se usaba la hipnosis como una terapia sintomática, como una condición para una
mejoria general y para descubrir e integrar recuerdos traumáticos. Para este ultimo propósito Breukink enfatizaba un
estado de calma mental, en estado hipnotico y de vigilia, desalentando la expresi6n emocional considerada peligrosa
para los pacientes psic6ticos. Se acuerda especial atención en la discusión al rol y peligros de la expresi6n de
emociones relacionadas con to traumático.
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Journal of Traumatic Stress, Vol. 6, No. 1, 1993